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April 18, 2017

Primary care patients at hospitals receive more unnecessary care, study finds

Daily Briefing

    Patients are more likely to receive unnecessary medical tests and services at hospital-based primary care practices than physician-owned community-based practices, according to a study published last week in JAMA Internal Medicine.  

    Study details

    For the study, researchers from the David Geffen School of Medicine at University of California-Los Angeles (UCLA) and Harvard Medical School compared 31,000 appointment records on outpatient visits to general internists over a 17-year period. The data, which were pulled from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, focused on patient visits for back pain, headache, and upper respiratory tract infection, which the researchers said represent three common primary care conditions.

    The researchers excluded visits for complex symptoms, which suggested more serious disorders, and accounted for patients with underlying disorders and chronic conditions to better identify people for whom tests and services offered little diagnostic or therapeutic value.  

    Study findings

    While the researchers found that both hospital-based and community-based clinics prescribed antibiotics at similar rates, primary care clinics at hospitals reported higher referral rates for CT scans, MRIs, X-rays, and specialist evaluations. 

    According to the study, patients who visited hospital clinics were referred for:

    • MRIs and CT scans 8 percent of the time, compared with 6 percent among patients who went to community clinics;
    • Specialist evaluations 19 percent of the time, compared with approximately 8 percent of the time at community-based clinics; and
    • X-rays 13 percent of the time, compared with 9 percent among patients at community-based clinics.

    John Mafi—the study's lead author, an assistant professor of medicine at UCLA, and a primary care physician at Ronald Reagan UCLA Medical Center—said physicians who work in hospitals might be more likely to refer patients for these follow-up visits due to convenience.

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    Bruce Landon, the study’s senior author and a professor at Harvard Medical School, said continuity of care might be an important issue. For example, when patients saw their own primary care physicians at a hospital-based clinic, there did not tend to be an overuse of unnecessary care, he said. However, when patients saw a physician covering for another colleague, there tended to be more unneeded referrals, he said.


    Mafi said reducing unnecessary care could curb health care costs, redirect hospital resources, and protect patients from potentially harmful effects. About a third of health care spending in the United States stems from services that provide low-value care, he noted. 

    Landon said awareness can help hospitals avoid overuse of certain tests and services that provide questionable therapeutic value for patients with common conditions. He added that this knowledge "can help both frontline clinicians and hospital leadership find ways to eliminate, or at least reduce, such unnecessary services" (Jones Sanborn, Healthcare Finance, 4/11; MacDonald ,FierceHealthcare, 4/11; Commins, Health Leaders Media, 4/11; UCLA release, 4/10).

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